The undersigned (or “Patient/Client”) agrees to the IV vitamin therapy administration by Aspire Health for the limited purpose of IV hydration, boosting immunity, and/or boosting athletic performance. Patient understands IV vitamin therapy affects patients in various ways and may not meet patients desired results. IV vitamin therapy is provided for pre or post-event health optimization purposes only, does not in any way constitute a medical diagnosis, and additional screening or procedures not provided by Aspire Health might be required in the event a medical diagnosis is desired. Patient acknowledges and agrees it is their sole responsibility to consult with the Patient’s personal health care provider with regard to his or her health concerns and to obtain any follow-up care determined by the health care provider to be appropriate. Further, patient understands that this screening is not a complete physical exam, and is not a substitute, therefore. Patient further understands that the administration of IV vitamin therapy requires a prick to patient’s skin and patient may experience some pain.
The undersigned agrees that he or she have truthfully disclosed all of Patient’s health related history and information requested. Patient understands that Aspire Health will not provide Patient’s medical health information to any physician or health care provider for any further review of any health condition that may be disclosed by patient.
The undersigned, on behalf of him or herself and his or her legal representatives, heirs, successors and assigns, does hereby release and forever discharge Aspire health and its agents, employees, successors and assigns, from any and all claims, losses, costs, expenses, and damages or any kind involving or related to errors, omissions, or negligence in the performance, procedures and administration of the IV vitamin therapy.
Contraindications for receiving hydration IV therapy are: HTN or uncontrolled blood pressure, Myasthenia Gravis, Kidney Failure, End-stage Kidney Disease, bleeding or clotting disorders, and those with heart disease such as taking digoxin, arrhythmias, atrial fibrillations, cardiomyopathy, CHF, etc.
By signing this consent form you agree to the following:
-Risks: allergic reaction to medications,
vein irritation, fluid overload, kidney
problems, headache, and pain at the
injection site.
-Rarely it may cause: vein inflammation,
metabolic disturbances, severe allergic
reaction, infection, cardiac arrest,
irregular heart beat, light-headedness,
muscle cramps, or irritation at the
injection site.
-Vitamin B12 is contraindicated in
Leber's disease.
-I am responsible for any medical care I
receive as a result of or related to my IV
hydration. If I have any side effects or
reactions, I agree that I am solely
responsible for payment of my medical
care.
I HAVE READ THIS AGREEMENT, CONSENT AND RELEASE OF LIABILITY, UNDERSTAND ITS TERMS, ALL MY QUESTIONS HAVE BEEN ANSWERED, I UNDERSTAND THAT I AM GIVING UP SUBSTANTIAL RIGHTS BY SIGNING IT, I UNDERSTAND ENGLISH OR HAVE HAD SOMEONE TRANSLATE THIS CONSENT FORM IN ITS ENTIRETY, AND HAVE SIGNED IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT, ASSURANCE OR GUARANTEE MADE TO ME. FURTHER, I INTEND MY SIGNATURE TO BE A COMPLETE AND UNCONDITIONAL WAIVER AND RELEASE OF ALL LIABILITY OF ASPIRE HEALTH AND ITS AGENTS, EMPLOYEES, SUCCESSORS AND ASSIGNS TO THE GREATEST EXTENT ALLOWED BY LAW.
